By way of an introduction from Mark Brown: The below is a blog post written March 2012 after attending a mental health and technology ‘unconference’ organised by the Young Foundation which details the results of what, for me, was probably the one of the most formative days of thinking I’ve ever done. In it you’ll see the beginnings of many of the thoughts I’ve developed further about mental health, technology, the business of innovation and how and why change does and doesn’t happen. I haven’t edited it since it originally appeared on the One in Four blog but thought it made sense to pull it together with the rest of the articles at The New Mental Health.
I spent Friday at #mindtech (http://unconferencementalhealth.wordpress.com/) [Note: this link will be dead but may be archived somewhere] An unconference to discuss using technology to make mental health better at Coin Street Community Centre on London’s South Bank.
The idea of the day was to get a load of people together in a big room, get them thinking and talking then get them to split up into groups and come up with ideas for projects. It was similar idea to the Innovation Labs I attended a few months ago.
Once people had come up with ideas for what could be discussed and we began to divide ourselves into groups, me and a couple of other people realised that what we were interested in didn’t seem to quite fit into the broad themes that others had identified. We decided it would make more sense for us to set up a little breakaway group of our own and see if we could come up with some ideas to present back to the unconference as a whole at the end of the day.
We made a break for the roof garden. As people who are intimately involved in mental health innovation rather than coming to it as a new idea, we tried to dig down into questions about how we do mental health innovation, how we can make it sustainable and what innovation actually means in mental health.
Below are some of my observations on the day and some of the things we ( Chris O’Sullivan ( @mentalcapital ), Katie Brown (@Re_connection) and Clodagh Miskelly (@miskellaneous )and me @markoneinfour) discussed up on the roof, sitting under a beautiful blue London sky.
Observation 1: There were less tech people than I would have expected
At an unconference about mental health and technology, I would have expected there to have been a larger contingent of people who were not mental health specialists but who were specialists in ‘doing tech’.
I think we sometimes have the idea that mental health is such a mystical and secluded area of endeavour that no outsiders will never get it. Tech people like solving problems. That’s why they are an asset (of which more further down).
Observation 2: Think big doesn’t mean make big things
Lots of people at #mindtech had big ideas.
This is brilliant. What we in our little rebel group explored a bit was what that actually means in terms of business models and sustainability.
The thing about things like apps and websites, that is tech that doesn’t involve manufacturing or giving people actual nuts and bolts bits of kit, is that the actual cost of development and delivery is more or less the same whether one person uses that app or website or one hundred thousand.
So, if you have a brilliant idea for an app and you spend £200.00 making it and twenty people use it and like it, you’ve spent £10.00 per person on making something positive happen. If a hundred people use it and like it, you’ve spent £2.00 per positive outcome.
The value of that form of tech is low-cost multiplication of impacts, like having a photocopier where you never have to refill the paper drawer or buy more ink. Once it’s built and launched, you should know exactly what you’re spending on each person who uses it and you should see the cost per person come down over time as more people use it.
At #mindtech I picked up a bias towards thinking about web applications or websites that would take on huge a weighty challenges and would provide all-singing, all-dancing solutions to them. This is a great and laudable aim, but it’s not how innovation or tech really works.
When presented with the question of how we can use technology to make the lives of people with mental health difficulties better, people can find themselves thinking about magic bullet solutions to make everything better which leads to very big, very broad project ideas.
The problem with massive ideas is that they have massive development costs. ‘ So what?’ you might say. The problem is that massive development costs massively increase the amount of people you need to use the thing you’ve created to make it worthwhile. Or in other words, to get a reasonable return on your investment you need a large amount of users and outcomes.
To come up with a tech answer that would provide an all-singing, all-dancing solution to a series of broad challenges that people with mental health difficulties will be time consuming, complicated and costly. If it’s taking on a massive range of challenges faced by a massive range of people, then I’d say that the cost of developing that will mean that you’ll also need a massive amount of people to use it to make for a good return in outcomes from the cash you’ve spent (or, more usually, the cash other people have spent by investing in you. It’s rare to find people who risk their own in developing stuff in mental health.)
If you want to be all things to all people by doing general things, then your innovation is going to need to be used by nearly all people to make it worth the investment.
The point that we would raise is: What’s wrong with small projects for specific purposes and people?
Observation 3: Improving mental health services isn’t synonymous with helping people with mental health difficulties to have a better life
This is a fairly self-explanatory observation.
Observation 4: We are awful at market research in mental health 1
One of the things that really struck me at #mindtech is that for the most part we still seem to be tit-awful at market research in mental health.
Market research is, very simply, the process you go through to take a product to market. It’s simple A level business studies stuff.
You find out what value the potential market has, you find out what other people are doing or have done in the past, you look for gaps or opportunities, you come up with products, you find what would be reasonable to charge for them, you find out how you offer them to the people you hope will buy them.
What really hit home to me in our rooftop discussion a #mindtech was just how disconnected and jumbled up this process is mental health. I was asked by John Loder of The Young Foundation to come and talk to the group he was helping out who were looking at ways to change perceptions of people with mental health difficulties. When they explained that they thought it would be great to do a big campaign collecting peoples stories and sharing them via social media to reduce stigma and that it could lead off with famous successful people through history who’ve experienced mental health difficulties I had to congratulate them. In the space of a few hours, a group of ten folk who’d never met before had run through all of the issues and ideas and possible solutions and had, in essence, come up with a plan that was pretty much the same as Time to Change’s plan for the first three year phase of their existence.
This is awesome, and shows that from a standing start, there are solutions that people will hit upon following logic, but that’s not really where the process of innovation begins.
Our small rooftop breakaway group was rooted, to an extent, in the fact that we have been doing that market research, we do know what others are doing or have been doing. In essence, our starting point was different. We spend our days thinking and working on projects that are about innovating and to do that we need to know what other people have done and are doing because that’s how we learn and how we make sure the time and resources we have can be used to their greatest value.
At present there isn’t really a primer in mental health innovation. I’m trying to raise the money to write and research one, but at present there isn’t really an easy starting point. [Note: despite trying crowdfunding we failed to raise the money to write and research this primer in mental health innovation. I hope that I've managed to capture and explore some of those issues over the following years of just getting on and doing stuff]
The first rule of Fight Club is you don’t talk about Fight Club. The first rule of mental health is that next to no one knows what anyone else is doing or has done in mental health.
There is isn’t a trade journal for mental health innovation, there are few websites, there isn’t a network. There’s some people doing stuff.
As Chris O’Sullivan suggested, we need a way of somehow creating a repository for stuff about mental health innovation so that we don’t reinvent the wheel.
For me, I wonder whether the default expectation that the state and the NHS will be the ultimate solution to the challenges that a mental health difficulty presents actually prevents us from seeing mental health innovation as an intellectual area in its own right.
When it comes to people with mental health difficulties trying to sort stuff out it sometimes feels that rather than speaking to each other, we go straight to speak to services. I wonder if we mirror that in our thinking about projects and innovation by just talking to funders and decision makers and failing to actually speak to our peers?
More broadly than that, at a very basic level you can’t innovate without knowing what’s happened before, which makes me think some thing even more intriguing: Maybe all of these ideas really were new to people who were used to working within services and structures? What seemed like a revolutionary eye opener to someone new to this notion of innovation and change in mental health may have been what had me sticking my hand up and saying ‘that’s great. There’s been projects that have done similar before.’
Innovation of course doesn’t need to be a new idea. It can be a very old idea applied in a new way. What to someone all wide-eyed with the rush of excitement that comes with first exploring a new ideas sounded like me pooh-poohing and saying ‘it’s all been done’ was actually me saying ‘the paths that have been explored in that direction have been interesting, explore further’.
At a more fundamental level, most people don’t know what people with mental health difficulties actually want, because they’ve never asked them. More broadly, most people don’t have a broad idea of where mental health difficulty fits into a life. We don’t see people with mental health difficulties in demographic terms. It’s still ‘take your medicine’. It’s like identifying that a) people like tea b) teapots sometimes leak and then trying to issue each person who likes tea in the country with a galvanised steel tea funnel which needs to be fitted to their tea cup by a qualified fitter.
The point we would raise is: How are people going to get ‘up to speed’ with what’s been happening and what does it say about the current situation that they aren’t?
Observation 5: We are awful at market research in mental health 2: The mental health pound
In our roof top breakout we were thinking a lot about sustainability, or to put it more bluntly, where’s the money?
What we realised is that in a situation where 82% percent of mental health services are still commissioned by by the NHS, it’s going to be a challenge to unshackle innovation in mental health from the particular needs and wishes of existing mental health services. They have the cash. They may not think they do, but they do.
This set us thinking more broadly about models for sustainable projects and sustainable innovation in mental health.
For something to be economically sustainable and to be able to offer a financial return on investment it needs to do the following: “it needs to sell people something they want, on terms they understand, at a price they’ll pay”.
Again, so far, so A level business studies. But, this gets complicated in mental health. Who really is the customer for mental health innovations? In other words, who is actually the consumer?
When we’re innovating we tend to think first of selling it to funders in mental health. We tend to think about selling to people with mental health difficulties last.
Let that sink in: We think last about selling our projects to the people who will use and benefit from them.
What kind of a sustainable business model is that? Think of the customer last?
What we realised is that no actually thinks of people with mental health difficulties as consumers in the classic sense, as people who can vote with the feet, purses and wallets. We didn’t even know any stats about how people with mental health difficulties actually use tech like the internet and smartphones, which you’d think would be important for something like #mindtech.
We realised that a major barrier to investment from beyond the NHS was the fact that we don’t actually know what people will and won’t pay for and at what price, because we’ve never found out. This set us wondering: What is the value of the overall mental health economy in the UK? How much is actually spent? We can get figures for NHS spending and perhaps social care spend and maybe charity spend. What about self funders? What about things that people with mental health difficulties spend their money on to help them to feel well?
Just what is the value of the mental health pound in the UK?
This may seem like an odd question but look at it in these terms: We complain about the under-investment in mental health, by which we usually mean the lack of money collected via taxation that in given to mental health services delivered by the NHS. If that is going to be increasingly squeezed by recession, what steps can we take to bring other investment into mental health and specifically mental health innovation?
The money has to come from somewhere (although there are ways of making money go much further by using it differently)
The NHS can be an excellent catalyst in mental health, but it still holds too many of the reins to make it possible for innovation to be truly disruptive. Very often it’s the people making the investment decision who are most challenged by radical innovations in mental health because those innovations don’t just modify how they do something but, in the way that the recovery model conflicts with the medical model, they modify what that something is.
In the spirit of disruptive innovation we would ask: Just what is the value of the mental pound in the UK and why don’t we find out what people want and would pay for?
Observation 6: Everyone can’t use it so no one can?
One thing I found really interesting at #mindtech was the idea that using a tech platform that more people use is better than using a specific platform that you definitely know some people use. When one of the introductory speakers was talking about Buddy, the mood feedback system, they said that they had decided against creating what they did as a smartphone app because many of their potential users don’t have smartphones.
This seemed to be translated by most at #mindtech into the assertion that most people with mental health difficulties don’t have smart phones therefore projects should be only be done on the platform that most people have access to, so in the case of all of the ideas that came out of #mindtech that meant doing websites.
In response to the point about smartphones, I tweeted that maybe we could stop whinging about people with mental health difficulties not having smartphones and just give people one if they don’t have one. Chris O’Sullivan pointed out that there are projects that have done just that and that it was a far cheaper thing to do than you’d imagine.
I think everyone who came to #mindtech passionately wants to change things for all people with mental health difficulties and this lent a utilitarian tone to many of the projects and ideas: the greats possible good for the greatest number of people.
I think that this either comes at tech innovation from a services improvement angle (How can we make tech part of services so services run better?) or an information provision angle (How can we give lots of information to lots of people?)
What was left out, I think, was the idea that tech is elective: You chose what you do and don’t choose to use. In existing services even the most simple forms of technology are elective; for example, some people choose to telephone to make an appointment, some would choose to do so in person, others might choose to use a different method if it was available.
There was still an air of medical thinking hanging over #mindtech, at least for me. There was a sense that the (probably accidental) consensus in some of the groups was how do we do a project for people to use? rather than how do we do a project that people will choose to use?
Yes, it’s obviously wrong to make the only way to book an appointment for your services an i-phone only app. That would be stupid. However, what if there is something that i-phones can do really well that an application related to people’s mental health might make use of?
Just because you can’t replicate the experience of using something for all people doesn’t mean that it should be discounted. My GP doesn’t know my email address because the practice has never asked. For my GP to send me emails rather than letters would be great for me, would save them money on postage and would be all together more efficient. I’d love it. It wouldn’t mean that alternative forms of communication shouldn’t be available. By the access logic, there’s no point in my GP exploring sending emails because we know ‘some’ people don’t have email addresses.
The point I’m driving at is that the idea of being able to build tech solutions to challenges that can be applied universally from day one is flawed.
The observation I’d feed back: Specific projects that do specific things with or for specific people are cheaper and less risky than big ones that do lots of things apparently for everybody
The observations we actually presented back to #mindtech (more or less)
High cost developments that need to be rolled out across thousands of people to justify the money that has been spent on them just mean that, counter intuitively, far more money is being risked, even if the universal nature seems to make them a better bet.
The NHS is rich with assets. Those assets are people and their knowledge, skills and ideas. At present they are sitting like funds in a dormant bank account, their additional potential to unlock mental health innovation unused.
Similarly, there is a huge amount of people with technical and business skills who want to make their communities a better place. These are assets that are not currently drawn into the world of mental health either.
Rather than bringing people to mental health tech projects that have been made by people with ‘their best interests at heart’, we would ask how can we take tech and mental health assets to people?
Instead of keeping assets locked up in statutory services and using them only to draw further funds into those services, instead of reinventing the wheel or do-gooding on behalf of people with mental health difficulties, why don’t we work on ways of giving knowledge and tech assets to existing groups to find ways of using those assets to come up with projects that meet their mental health needs?
Or even to come up with micro enterprise ideas that involve coming up with services that can be sold or invested in?
We’d suggest small amounts of money can go a long way to supporting the process of innovation for solving problems for small groups of people and that fostering small innovations in communities in mental health and tech might actually come up with more ideas that can be developed or tried in other places or with other groups.
People in communities may not have specialist knowledge but they have ideas and experiences. If we are sitting on a huge store of knowledge and expertise then we should be looking to spread innovation to community level so that when mental health and tech ideas happen they happen with the full involvement of the people who are supposed to benefit from them.
Big isn’t always better and for innovation to be disruptive and really change things it needs freedom to happen. Improving services is awesome, but that’s not the only thing innovation in mental health can do.
There’s a lot more that I could say about what we were discussing up on the roof, but I think that’s enough to be going on with. Hopefully Chris O’Sullivan ( @mentalcapital ), Katie Brown (@Re_connection) and Clodagh Miskelly (@miskellaneous ) will be blogging or writing up some of their thoughts.
(This post originally appeared under the title ‘#mindtech – Observations from a Rooftop’ at the One in Four blog
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter